MX2013001920A

MX2013001920A - Surgical set of instruments for precision cutting.

Info

Publication number: MX2013001920A
Application number: MX2013001920A
Authority: MX
Inventors: Jose Dinis Carmo
Original assignee: Jose Dinis Carmo
Priority date: 2010-08-18
Filing date: 2010-12-10
Publication date: 2013-06-05
Also published as: JP5768130B2; IL224712A; ES2641489T3; EP2605714B1; PT2605714T; CA2808480A1; KR101756773B1; PT105255A; KR20130099031A; CA2808480C; DK2605714T3; CN103153215A; US20130144318A1; MX352235B; BR112013003719B1; WO2012023006A1; EP2605714A1; JP2013534166A; US9782192B2; AU2010359164B2

Abstract

A method and set of instruments are disclosed particularly for carpal tunnel surgeries allowing a precision cut in the transverse carpal ligament (TCL) without direct vision or exposure of the ligament, except for its most proximal edge, but with guidance and safety of the cutting knife, eliminating or, at least, very much decreasing, the probability of cutting lines in the wrong direction and inadvertent (iatrogenic) lesions to the surrounding structures, comprising, in a preferred embodiment: a uniquely shaped cannulated guide rod, through which passes a flexible metal guide needle (33) which serves as a guideline for a uniquely shaped cutting knife or fasciotome (25) having a cannulated finger-like prong in the inferior edge of the blade portion of the knife plus, in a second embodiment of the invention, a sphere (32) coupled to the tip of the superior blunt finger-like prong present in the superior edge of said blade portion of said knife; a uniquely shaped cutting knife or fasciotome with a curved shaft at 90° with, in a second embodiment of the invention, a pair of spheres coupled to the tip of two blunt finger- like prongs and an optional uniquely shaped slotted guide cannula (40) with a fenestration at its end tip allowing for the passage of the flexible metal guide needle (33) and, in a second embodiment of the invention, also a restraining metal arch or arch-brake (37) near its distal extremity and at its rear, two ears / handles for its proper handling.

Description

SURGICAL SET OF INSTRUMENTS PAPA PRECISION CUTTING FIELD OF THE INVENTION This invention relates to a set of surgical instruments for precision cutting, particularly suitable for carpal tunnel release surgeries. The method for carrying out the release is also disclosed.

The surgical set of instruments developed for use especially, but not exclusively, in carpal tunnel release surgery, comprises a cannulated guide bar, a cutting knife or fasciotome, a cutting knife or fasciotome with an axis curved at 90 ° and a slotted guide cannula. The present invention comprises a method for carrying out a transverse release of the carpal tunnel which is designed to be carried out without the need to expose and / or visualize the entire ligament before cutting, although with full control and precision of cutting of the release , eliminating or, at least, greatly diminishing, the probability of cutting lines in the wrong direction and unnoticed (iatrogenic) injuries to the surrounding structures.

BACKGROUND OF THE INVENTION Carpal tunnel syndrome is a complex of symptoms resulting from compression of the median nerve in the carpal tunnel. The carpal tunnel is the osseous-rigorous passage for the median nerve and the flexor tendons, formed by the retinaculum and the carpal bones. The carpal bones are the bones of the carpus. The carpus or wrist is the region of the joint between the forearm and the hand, which is composed of eight bones. The flexor retinaculum or transverse carpal ligament is a heavy fibrous continuous band with the distal part of the antebrachial fascia, completing the carpal tunnel. The antebrachial fascia or (fundus) forearm fascia is the inversion fascia of the forearm. The patient is a sheet or band of fibrous tissues that lies under the skin or forms an inversion for the muscles (and different organs of the body).

The treatment of carpal tunnel syndrome by releasing the transverse carpal ligament has been used for more than 60 years. During that time, several methods have been developed to release the ligament.

In summary, they can be classified into two large groups: 1) open methods, using an incision in the skin of the palmar aspect of the palm on the ligament and 2) endoscopic methods. The endoscopic methods can be further divided into two subgroups: 2) a) one using a single incision and 2) b) another using two incisions, with at least one in the palm of the patient. 1) The open methods are all those that are carried out basically in the same way, with some variants, referring mainly to the length of the skin incision and / or its exact position in the palm. Although they are very effective in alleviating the symptoms of most patients and safe (the safety of the procedure generally varies inversely with the length of the scar) they may require relatively prolonged post-operative recovery for the hand and are often complicated by the sensitivity around of the site of incision and pain called "pillar pain" (pain pillar) at the base of the thenar and hypothenar imminence, only distal to the fold of the wrist and on each side of the surgical scar.

References in this regard are US Pat. Nos. 5,387,222 02/1995, Strickland, Carpal Tunnel Tome and Carpal Tunnel Surgery, (Volume of the Carpal Tunnel and Carpal Tunnel Release Surgery); No. 5,413,5802 05/1995, Stephenson, Carpal Tunnel Knife, (Carpal Tunnel Knife); No. 5,908,433 06/1999, Eager, Carpal Tunnel Knife, (Carpal Tunnel Knife). 2) In an attempt to minimize these complications, several endoscopic methods were developed for the division of the transverse carpal ligament, receiving considerable popularity especially during the 80s and 90s.

In general, these techniques employ the passage of a special instrument below the transverse carpal ligament, such as, for example, the method shown in U.S. Patent No. 5,273,024 to Menon, and then use optical fiber. and special cutting devices to observe and divide the ligament. However, these techniques are fraught with problems, including the need for expensive special equipment, requiring specialized training and extensive learning curves by the surgeon, which is a fairly time-consuming procedure. They have also met the challenge of not always being consistent in their ability to completely divide the transverse carpal ligament and there are reports of complications such as iatrogenic injury to the contents of the carpal tunnel, ie the median nerve and its branches and tendons within the Carpal tunnel. In some cases, the instrument was taken inside a wrong step causing injury to the ulnar nerve and artery. Frequently, during the operation, the vision of structures destined significantly impaired by the fogging of the tip of the lenses of the optical instrument, or by palmar fat that falls in the field of work while the transverse carpal ligament is being released. If the technique involves the use of a "small" palmar incision, the problem of local pain and abutment can be diminished but not completely eliminated.

In addition to all these reasons, it is the personal opinion of the inventor that one of the biggest drawbacks of endoscopic techniques is the need for prior dilatation of the contents of the carpal tunnel, using enough "dilators" to make room to introduce the cutting apparatus. The fundamental reason why the carpal tunnel syndrome develops in the first place is due to the fact that the structures that adjoin and fill the carpal vault are virtually incompressible, therefore, if the contents swell, the median nerve is compressed activating the symptom. "Dilate" the contents of the channel adds to the same problem that one tries to solve, at least temporarily, and is potentially dangerous because the pressure can move structures on or in front of the cutting instrument, placing it seriously in danger.

Reference is made to U.S. Patent Documents No. 5,273,024 12/1993, Menon, Method and Apparatus for Performing Endoscopic Surgery, (Method and Apparatus for Performing Endoscopic Surgery); No. 5,334,214 08/1994, Putnam, Apparatus and Method for Dividing Transverse Carpal Ligament, (Apparatus and Method to Divide the Transverse Carpal Ligament).

Therefore, what is needed is a simple, safe, effective, and economical technique that requires only an incision of the simple wrist, in order to avoid or minimize both the complications and the operational burdens.

In summary, the advantages offered by the present invention through current art are the following: In relation to 1) open methods: 1) Completely avoid any incision in the palm of the hand, therefore, eliminate or greatly reduce the pain of the incision and the "pillar pain". 2) Smaller incision through the distal fold of the wrist. 3) Less post-operative pain. 4) Better cosmetic result: this incision becomes undetectable quickly (in a few months) for all practical aspects.

In relation to 2) endoscopic methods: Much simpler technique, avoiding: 1) The need for special (very) expensive equipment: the technique involves the use of only 4 or 5 simple, inexpensive tools. 2) The need for specialized training extensive learning curves by the surgeon. 3) Quick procedure. 4) Without the need for prior expansion of the contents of the carpal tunnel. 5) able to ensure a complete release of the ligament in all cases. 6) Safe technique: in more than 100 cases carried out by the inventor no cases of major complications have been detected.

BRIEF DESCRIPTION OF THE INVENTION For the purposes of promoting and understanding the principles of the invention, reference will now be made to the modality illustrated in the drawings and specific language will be used to describe the same. However, it will be understood that no limitation of the scope of the invention is intended, such alterations and further modifications to the devices as illustrated, and such further applications of the principles of the invention as illustrated in this regard are contemplated as would normally occur for someone experienced in the matter to which the invention relates.

The present invention relates to a set of surgical instruments particularly suitable, but not exclusively, for carpal tunnel release surgeries, and their method of use, which allows the performance of an incision in the TCL without direct visualization of the ligament, except for its most proximal edge, but with guidance and safety when handling the knife, eliminating or greatly reducing the likelihood of cutting lines in the wrong direction. Said set comprises: A cannulated guide bar (28), Figure 10, with a curved distal end, which guides the passage of a flexible metal guide wire (33) through the selected point in the palm of the hand.

A cutting knife or fasciotome (25), Figure 12, comprising at least one cannulated finger-like pin (20 or 24) attached to the inner surface of the knife holder (21) located in the head portion of the knife. device, and one or two solid finger-like pegs (22; 23) that extend forward above and below the razor, similar to the type of surgical knife found in U.S. Pat. 5,387,222 issued to Strickland.

Alternatively, the lower end of the knife portion may be flat or rounded at the end, extending below the blade, replacing the solid bottom finger-like plug (22). Attached to the lower surface of said cannulated finger-like peg (22), or its replacement surface, there are one or two voided pegs similar to a finger (20 and 24). The purpose of such annulled finger-like pegs is to allow the passage of the flexible metal guide wire (33), after this needle is placed below the lower surface of the (TCL) (106), with the aid of the curved cannulated guide bar (28). This needle guided the progress of said razor (21) of said distal end of the fasciotome (25) during the cutting action, therefore, eliminating the possibility of the device deviating from the intended route to any other wrong step. . In the distal part of the fasciotome axis (25) there is only a set of holes or fenestrations (26), placed at regular distances, referenced from the tip of the instrument and between them for the purpose of determining the length of the device inserted into the palm and therefore the cut length of the transverse carpal ligament (TCL).

The fasciotome also includes a handle or handle (34) attached to the proximal (rear) end of the shaft, in order to make the device's thrust easier and safer along the entire ligament, as shown in Figure 15. At the end of the finger-like upper pin there is a metal sphere (32), in a preferred form of mode, with the preferred size of 2 mm, preferably placed eccentrically in order not to decrease the width of the razor. This sphere increases the dullness of the finger-like peg, virtually eliminating the possibility that the knife will deviate from the intended route, ie downward, through the transverse carpal ligament (TCL), into the median nerve and tendons. . However, its preferred size does not interfere with the forward advancement of the fasciotome.

A cutting knife or fasciotome with a curved 90 ° angled shaft (41), coupled to any type of handle that the surgeon may consider appropriate for use, and a knife holder with a knife (21) portion limited by two solid finger-like pegs (22; 23) at the tip, extending forward above and below the razor, similar to the type of surgical knife found in U.S. Patent No. 5,387,222, issued to Strickland. Alternatively, the lower end of the knife may be flat or rounded at the end, extending below the knife the same distance, replacing the lower pin similar to a finger (22). At the end of each finger-like plug there is preferably a metal sphere (32), with the preferred size of 2 mm, preferably placed eccentrically, in order not to decrease the width of the knife portion. These spheres increase the bluntness of the finger-like pegs, virtually eliminating the possibility of the razor deviating from the intended path, either superficially, which could result in an incomplete cut or no cut of the distal antebrachial fascia. or down, through the transverse palmar ligament, to the median nerve and tendons. However, this preferred size does not interfere with the forward advancement of the fasciotome.

A slotted (guide) cannula (40), with a closed but fenestrated distal end, by means of a central hole (33A), and an open proximal end, the cannula provided with a longitudinal slot (39) extending from a point adjacent to the distal end cannulated to a point adjacent the open proximal end. The cannula may have a C-shaped or D-shaped inner cross section with the flat part of the C or D shape positioned along the edge of the longitudinal groove.

The groove guides the fasciotome and the fenestration at the distal end allows the passage of the flexible guide needle that will lead to the fasciotome through the transverse carpal ligament (TCL) (106), placed first under the guidance of the curved cannulated guide bar (28). ).

In this preferred embodiment, there is also, near the distal end of the cannula, an arch brake (37) which helps: a) to restrict the final progress of the knife portion (21) of said fasciotome (25), which it is another element that prevents the knife from moving forward or upward, towards the palm of the hand, as illustrated in Figure 14; b) to push aside the soft tissues under the TCL, and c) to improve the surgeon's sense of touch of the lower surface of the TCL. At the open distal end, there is a pair of handles or ears (38) for ease of handling, as illustrated in Figure 17.

BRIEF DESCRIPTION OF THE DRAWINGS Figure 1 is a schematic view of the palm and wrist of a human showing some anatomical structures and some of the marks in addition to the surgical incision that are used during the procedure that is described in this document, in which the numbers represent the next: 104 -. 104 - Tendon of the long palmar muscle 105 -. 105 - Pisiform bone 106 -. 106 - Transverse Carpal Ligament (TCL) 107 -. 107 - Hook of the haunch bone 202 -. 202 - Line drawn as the continuation of the radial edge of the ring finger 203 -. 203 - Line drawn as the continuation of the ulnar border of the ring finger 207 -. 207 - Cardinal line of Kaplan 208 -. 208 - Fourth metacarpal 304 -. 304 - Distal palmar crease of the wrist 305 -. 305 - Surgical incision Figure 2 is a schematic view of the palm and wrist of a human showing the surgical incision in the skin, the edges of the skin retracted from behind by two skin hooks and a knife that performs a transverse surgical incision in the skin. fascia of the wrist that is used during the procedure described in this document, in which the numbers represent the following: 304 -. 304 - Distal palmar crease of the wrist 305 -. 305 -. 305 -. 305 -. 305 - Surgical incision (edge of the skin) 401 and 401A - skin hooks 402 -. 402 - Knife (surgical knife) 405 -. 405 - Proximal edge of the transverse carpal ligament (TCL) 405A - Distal border of the antebrachial fascia (palmar carpal ligament (PCL, Palmar Carpal Ligament)) 406 -. 406 - Adson Forceps 407 -. 407 - Surgical incision in the palmar fascia Figure 3 is a schematic view of the palm and wrist of a human showing the 90 ° angulated curved axis fasciotome that cuts the distal edge of the antebrachial fascia, during a part of the procedure described herein, in the which numbers represent the following: 41 -. 41 - 90 ° angled fasciotome 106 -. 106 -. 106 -. 106 - Transverse carpal ligament 305 - Surgical incision 405A - Antebrachial fascia (palmar carpal ligament (PCL)) 501B - Skin 502B - Subcutaneous fat 504 -. 504 - Proximal edge in the distal antebrachial fascia Figure 4A is a schematic view of the palm and wrist of a human showing a blunt probe an obturator being inserted distally below the transverse carpal ligament (TCL) during a portion of the procedure described herein, in which numbers represent the same as indicated under Figure 4C.

Figure 4B is an enlarged view of a portion of Figure 4A showing a sagittal view of the blunt probe or obturator inserted distally below the transverse carpal ligament (TCL), in which the numbers represent the same as indicated under Figure 4C.

Figure 4C shows the same sagittal view as Figure 4B with the dull probe or obturator replaced by the cannulated curved tip guide bar which is part of the invention described herein, in which the numbers represent the following: 27 -. 27 -. 27 - Cannulated guide bar with curved tip 106 - Transverse Carpal Ligament (TCL) 401 -. 401 - Leather hook 305 - Surgical incision 405A - Forebrachial fascia (palmar carpal ligament) 501B - Skin 502B - Subcutaneous fat 601 -. 601 - Dull or shutter probe 607 -. 607 - Laser Markings of the Curved Cannulated Guide Bar Figure 5A is a schematic view of the palm and wrist of a human showing: 1) a flexible metal guide wire being introduced below the deep surface of the transverse carpal ligament (TCL) through the lumen of the cannulated curved tip guide bar which is part of the invention described herein during the procedure which is the subject of the present and, 2) the palm of the hand distal to the referenced Kaplan line that is pressed down with a dull spatula to facilitate the extrusion of the tip of the flexible needle, in which the numbers represent the same as indicated under Figure 5B.

Figure 5B is a sagittal view, on a larger scale, of a portion of Figure 5A showing the same procedure illustrated in the previous figure, in which the numbers represent the following: 27 - Cannulated guide shaft with curved tip 33 -. 33 - Flexible metal guide needle 106 - Transverse Carpal Ligament (TCL) 305 - Surgical incision 405 -. 405 - Proximal edge of the transverse carpal ligament (TCL) 501B - Skin 502B - Subcutaneous fat 706 -. 706 - Spatula Figure 6 is a schematic view of the palm and wrist of a human showing the cannulated finger-like peg of the distal end of the fasciotome of the transverse carpal ligament that is part of the invention described herein and introduced throughout the guide wire of flexible metal placed below the carpal transversal ligament (TCL), during the procedure that is the subject of the present, in which the numbers represent the following: twenty - . 20 - Cannulated peg similar to a finger twenty-one - . 21 - Knife (cutting edge of the knife) 25 -. 25 -. 25 -. 25 - Fasciotome 26 -. 26 -. 26 -. 26 - Fenestrations in the fasciotome axis 32 -. 32 -. 32 - Metal sphere 33 -. 33 -. 33 -. 33 - Flexible metal guide needle 106 -. 106 -. 106 -. 106 - Transverse Carpal Ligament (TCL) 305 -. 305 - Surgical incision 405 -. 405 -. 405 - Proximal edge of the transverse carpal ligament (TCL) 810 -. 810 -. 810 -. 810 - Wire Figure 7 is a schematic view of the palm and wrist of a human, the fasciotome of the transverse carpal ligament (TCL) which is part of the invention described herein being tucked into the proximal edge of the transverse carpal ligament (TCL) , extending over the ligament, under the guidance of the flexible metal guide needle which is kept under tension with the help of two strong needle supports (not shown), during the procedure which is the subject of the present, in which the numbers represent the following: twenty - . 20 - Cannulated peg similar to a finger twenty-one - . 21 - Knife (cutting edge of the knife) 25 - Fasciotome 26 - Fenestrations in the fasciotome axis 32 - Metal sphere 33 - Flexible metal guide needle 106 - Transverse Carpal Ligament (TCL) 405 - Proximal edge of the transverse carpal ligament (TCL) 405A - Antebrachial fascia (palmar carpal ligament (PCL)) 810 - Wire Figure 8A is a schematic view of the palm and wrist of a human, illustrating the complete division of the transverse carpal ligament (TCL) by the progression of the fasciotome of the transverse carpal ligament (TCL), under the guidance of the metal guide wire flexible, along the entire length of the ligament (TCL), in which the numbers represent the same as indicated under Figure 8C.

Figure 8B is an enlarged view of a portion of Figure 8A showing a sagittal plan view of the same procedure described, the cut of the transverse carpal ligament (TCL) in which the numbers represent the same as indicated under the Figure 8C.

Figure 8C is an enlarged view of a portion of Figure 8A showing a cross-sectional plan view of the same procedure described, the section of the transverse carpal ligament (TCL), in which the numbers represent the following: 25 - Fasciotome 26 - Fenestrations in the fasciotome axis 33 - Flexible metal guide needle 106 - Transverse Carpal Ligament (TCL) 810 - Wire 405A - Forebrachial fascia (palmar carpal ligament) 501B - Skin Figure 9A is a schematic view of the palm and wrist of a human illustrating the use of the optional slotted, fenestrated tip guide cannula, which is part of the invention described herein, introduced below the transverse carpal ligament (TCL), under the guidance of the flexible metal guide needle enter through its fenestrated tip, in which the numbers represent the same as indicated under Figure 9D.

Figure 9B is an enlarged view of a portion of Figure 9A, illustrating a sagittal plan view of the same procedure, the complete insertion under the transverse carpal ligament (TCL) of the slotted guide cannula, fenestrated tipped until it is it stops progressing further by means of the flexible metal guide needle that rests against the deep surface of the palmar skin, in which the numbers represent the same as indicated under Figure 9D.

Figure 9C shows the same planar view as Figure 9B, illustrating the surgical step that follows in the procedure that is the subject of the present, which consists of the initial introduction of the fasciotome of the transverse carpal ligament (TCL) throughout the guide wire of flexible metal that is along the longitudinal groove of the slotted guide cannula, of fenestrated tip, in which the numbers represent the same as indicated under Figure 9D.

Figure 9D shows the same flat view as Figure 9C with the fasciotome of the transverse carpal ligament (TCL) fully inserted along the longitudinal groove of the grooved, fenestrated tip guide cannula along the transverse carpal ligament (TCL) ) sectioned, in which the numbers represent the following: 25 -. 25 -. 25 - Fasciotome 33 -. 33 -. 33 - Flexible metal guide needle 40 -. 40 -. 40 -. 40 - Slotted guide cannula, fenestrated tip 105 -. 105 - Pisiform bone 106 -. 106 - Transverse Carpal Ligament (TCL) 305 -. 305 - Guiding incision 501B - Skin 502B - Subcutaneous fat Figure 10 is a 3D view of a preferred form of the cannulated guide bar with a curved tip, which is part of the invention described herein, with a "nail" at the tip of the shaft coupled to a shape suitable rear handle, in which the numbers represent the following: 27 -. 27 - Handle of the cannulated guide bar with curved tip 28 -. 28 - Shaft of the cannulated bar 29 -. 29 - Curved distal end of the cannulated bar 30 -. 30 -. 30 - Tooth or nail Figures 11A and 11B are enlarged 3D views of a portion of Figure 10, highlighting the tip of the curved cannulated guide bar, in two of the preferred modes of mode, with a "tooth" or "nail" in its distal end, in which the numbers represent the following: 30 - Tooth 31 -. 31 - Uña Figure 12 is a 3D view of one of the preferred forms of distal end mode of the straight axis fasciotome that is part of the invention described herein, in which the numbers represent the following: twenty - . twenty - . 20 - Cannulated peg similar to a finger twenty-one - . twenty-one - . 21 - Knife (cutting edge of the knife) 22 -. 22 -. 22 - Bottom peg similar to a finger 2. 3 - . 2. 3 - . 23 - Top peg similar to a finger 32 -. 32 -. 32 -. 32 - Metal sphere Figure 13 is a 3D view of another preferred form of modality of the distal end of the fasciotome axis of the transverse carpal ligament (TCL) which is part of the invention described herein, having two parallel cannulated pegs similar to a finger, in which the numbers represent the following: 20 - Cannulated peg similar to a finger 21 - Knife (cutting edge of the knife) 22 - Bottom peg similar to a finger 23 - Top peg similar to a finger 24 -. 24 - Cannulated peg similar to a finger 25 -. 25 -. 25 - Fasciotome 26 -. 26 - Fenestrations in the fasciotome axis 32 - Metal sphere Figure 14 is a 3D view, distal to proximal, of the assembly consisting of the flexible metal guide wire that is used in the procedure that is the subject of the present, the slotted guide cannula, fenestrated tip, and the knife transverse carpal tunnel snipping or fasciotome, in a preferred form of embodiment, with a metal sphere at the tip of the distal upper peg similar to a finger on the head portion of the fasciotome which are both part of the invention that is described in this document, in which the numbers represent the following: 25 - Fasciotome 32 - Metal sphere 33 - Flexible metal guide needle 37 -. 37 - Arch of restraint metal or arch brake 40 - Slotted guide cannula, fenestrated tip Figure 15 is the same 3D view, proximal to distal, of the assembly shown in Figure 14, illustrating the preferred shape of the rear handle of the cutting knife of the straight axis carpal tunnel or fasciotome, which is part of the invention described in this document, in which the numbers represent the following: 25 - Fasciotome 3. 4 - . 34 - Rear handle 40 - Slotted guide cannula, fenestrated tip Figure 16 is a 3D view, distal to proximal, of the fasciotome of the 90 ° curved shaft that is part of the invention described herein, coupled to a suitable form of rear handle, in which the numbers represent the following: 41 -. 41 - 90 ° angled fasciotome 42 -. 42 - Metal sphere Figure 17 is a 3D view, distal to proximal, of the assembly consisting of the flexible metal guide wire that is used in the procedure that is the subject of the present, positioned along the longitudinal slot of the guide cannula slotted, fenestrated tip, which is part of the invention described herein, with its tip exiting through the closed fenestrated distal end of the cannula. The restriction metal arch in the distal dorsal axis of the cannula is also illustrated. The numbers represent the following: 33 -. 33 -. 33 - Flexible metal guide needle 37 -. 37 -. 37 -. 37 - Arch of restraint metal or arch brake 38 -. 38 -. 38 - Ears / handles 39 -. 39 -. 39 - Longitudinal groove 40 -. 40 - Slotted guide cannula, fenestrated tip Figure 18 is an enlarged 3D view, proximal to distal, of the distal end assembly consisting of the flexible metal guide wire that is used in the procedure that is the subject of the present, placed along the longitudinal groove of a preferred form of the slotted, fenestrated tip guide cannula that is part of the invention described herein with its tip exiting through the fenestrated closed distal end of the cannula. The restriction metal arch in the distal dorsal axis of the cannula is also illustrated. The numbers represent the following: 33 - Flexible metal guide needle 33A - Front hole of slotted guide cannula, fenestrated tip 37 - Arch of restraint metal or arch brake 39 - Longitudinal groove Figure 19 is a 3D view, distal to proximal, of the assembly of the instruments that are part of the invention described herein, that is, from left to right: the cannulated guide bar, the ligament cutting knife transverse carpal or fasciotome in the groove of the slotted guide cannula, fenestrated tip and knife cutout or fasciotome with a curved axis of 90 °, in which the numbers represent the following: 25 -. 25 - Fasciotome 27 -. 27 - Handle of the cannulated guide bar with curved tip 33 - Flexible metal guide pin 37 - Arch of restraint metal or arch brake 38 - Ears / handles 40 -. 40 - Slotted guide cannula, fenestrated tip 41 -. 41 - 90 ° angled fasciotome DETAILED DESCRIPTION OF THE INVENTION The present invention discloses a set of surgical instruments particularly, but not exclusively, suitable for cutting the transverse carpal ligament (TCL) during carpal tunnel surgery and its method of use, comprising: A cannulated guide bar (28) having, preferably, a cylindrical section and two open ends, with a curved distal end (29). Its lumen allows the introduction of a flexible metal guide wire (33), the guide for the knife portion of the cutting knife of the carpal ligament or fasciotome (25). The instrument is characterized by having an appropriate size and shape in order to optimize its introduction into the palm, below the inferior surface of the transverse carpal ligament (TCL), through a minimal surgical incision, and also guides the introduction of said guide wire (33) to a selected point in the palm of the hand.

In addition, said bar (28) is characterized by having, approximately 1 cm from its distal end, a buckling (29) with an angle of approximately 25 ° to 30 °, in order to: facilitate its introduction below the lower surface of the FTA; push up with your tip from the bottom surface of the TLC; improve the sense of touch of the surgeon of said ligament and its distal edge and guide the tip of the guide needle (33) upwards in the direction of the surface of the palm of the hand, in such a way that the tip of the needle will extrude at a point in the palm near the tip of said bar.

In a preferred form of the embodiment, said bar (28) is still characterized by having attached to the tip of the most distal edge of its curved end, on the side of the convexity, a projection, such as a tooth (30) or nail ( 31), of at least 1 mm high, as shown in Figure 11A and 11B, facilitating and improving the surgeon's tactile sense of the lower surface of the TLC, also improving the sense of a pull when the edge is exceeded. distal ligament. As part of the measures designed to avoid incomplete cutting of the TLC, in the distal upper surface of the shaft (28), considered to be the side of its concavity, it can be recorded, by one of several means known in the art, with a Metric scale (607) for the dual purpose of referencing at all times to which direction the tip of the bar is pointing and to determine the length of the device inserted in the palm, as shown in Figure 10.

Said rod must be manufactured, by one of several means known in the art, with biocompatible metal, such as surgical stainless steel or iron based, titanium based, cobalt based or any other suitable alloy, with the following preferred dimensions , which can be altered for manufacturing purposes or to adjust to the economic conditions of the surgeon: · Length: 50 to 100 mm • External diameter: 3-5 mm • Internal diameter: 2-3 mm This cannulated guide bar (28) can be coupled with any type of handle as is convenient for its manufacture and for the surgeon to control and maneuver the instrument. Said handle can be manufactured, by one of several means known in the art, preferably with either a metal alloy of the same kind of the bar or a biocompatible material resistant to high temperatures, eg, high density polyethylene or another from the family of plastics.

In any case, it is critical that the proximal end of the bar (28) is always visible and permeable on the side of the handle to allow insertion of the flexible metal guide wire (33) into the lumen of the instrument.

The proposed assembly of this invention also includes a cutting knife or fasciotome (25) comprising at least one cannulated, tubular, finger-like plug (20 or 24) which may be coupled to a solid finger-like plug (22). ) present on the lower surface of the cutting blade (21) or, alternatively, can even replace it, if the lower end of the blade holder, in a preferred form of embodiment, is made flat or flattened, rounded at its tip , allowing the direct fixation to it of said cannulated tubular plug (20). The purpose of said cannulated, finger-like plug (20) is to guide the passage of the flexible metal guide wire (33) after it has been positioned in place with the help of the cannulated guide bar (28). This needle will guide the progress of the razor portion (21) of said knife or fasciotome, during the cutting action, eliminating the possibility of the device deviating from the intended route in a wrong step.

Said fasciotome is also characterized by having, in a preferred form of embodiment, attached to the tip of the finger-like upper solid plug (23) a metal sphere (32), with the preferred size of 2 mm, preferably placed in eccentric manner in order to decrease the width of the knife portion (21). This sphere (32) also increases the security, by improving the bluntness of said solid finger-like peg (23), virtually eliminating the possibility that the knife (21) deviates from the intended route in a wrong step, that is, downwards, through the transverse carpal ligament (106), towards the median nerve and tendons. However, its preferred size does not interfere with the forward advancement of the fasciotome. Said fasciotome also has, in a preferred form of embodiment, in the distal part of the axis of the fasciotome (25) in at least two of its sides or edges, a group of fenestrations (26), placed at regular distances, referenced between and from the tip of the instrument, forming a scale that the surgeon can use to verify the length of the device that has advanced inside the hand and, therefore, the length of the cut carried out in the TCL (106).

Said fasciotome also includes a handle (34), Figure 15, in order to make it easier to push the instrument through the ligament. This cutting knife or fasciotome (25) can be manufactured, by one of several means known in the art, with biocompatible material, in two different forms: "disposable" and "non-disposable" or "permanent", in the preferred form of modality: 1) The "disposable" fasciotome consists of a front or distal razor portion made of stainless steel or any other biocompatible, high strength metal alloy coupled with a disposable, manufactured back shaft and handle by one of several means known in the art. The material, with a biocompatible material resistant to high temperatures, eg, high density polyethylene or another family of plastics. 2) The permanent or "non-disposable" fasciotome is manufactured, by one of several means known in the art, as a completely metallic piece, made of surgical stainless steel or any other biocompatible, high-strength metal alloy, such as those described for the cannulated guide bar (28).

The remaining structural parts of the cutting knife / fasciotome (25) and their preferred dimensions, which can be altered for reasons of industrial manufacturing convenience or to suit the economic characteristics of the surgeon, without this meaning that we are facing a new instrument, continue: Rear handle Trapezoidal, with a main longitudinal axis, concave-convex, with the concavity towards the opposite side of the axis, crossed transversely by a set of low relief grooves (grooves) across its entire width.

Recommended dimensions: • Length: 29 mm • Width: 10 mm • Thickness: 5 mm • Gaps in the concave surface of the handle, towards the opposite side of the stem: 1 mm deep (low relief).

Connection to the shaft or shank Mounted perpendicularly thereto, at the rear end of said axis, in a form that its bottom transverse side does not leave more than about 5 mm below the lower surface of said axis and this configuration allows to fulfill the following objectives: 1) Provide a comfortable surface and functional support for the thumb to push the fasciotome (25) along the TCL during the cutting action. 2) Have an ergonomic configuration, to adopt the thumb to the convexity of the side of the palm. 3) The slits contribute to the stability of the instrument by increasing adhesion / friction between the device and the gloved thumb during surgery. 4) The detail of the cable that is attached to the stem in the manner described, eccentrically upwards, prevents the handle from striking the palmar surface of the patient's forearm while pushing the fasciotome (25) forward, towards the hand, so thus hindering the progress of the instrument during the cutting process of the TCL.

Shaft or stem Proximal end (posterior) In a preferred form of mode, with a square section, with the following recommended lateral dimension: 6 mm Diaphysis In its preferred mode of shape, with a square proximal section, in continuity with the proximal (posterior) end approximately 100 mm away from the posterior end, the shaft gradually increases towards its distal end and assumes a pyramidal, preferentially flattened shape on the transverse axis , acquiring greater height than width.

Recommended dimensions (diaphysis only): • Length: 130-140 mm.

· Proximal width up to 100 mm away from the rear end: 6 mm side, preferably with a square configuration.

• Gradual increase of the rod from this point onwards, until it reaches the dimensions of 4 mm on the vertical axis in the neck of the stem, 140 mm from the rear of the device and 25 mm proximal to the tip of the device.

• Progressive narrowing of the rod from the same point to 2 mm on the transverse axis, at the level of the stem neck, 140 mm from the rear of the device and 25 mm proximal to the tip of the device.

The shaft is fenestrated along its vertical, horizontal side or both, by a preferred number of five holes, arranged at equal distances between them, preferably 5 mm, starting at 30 mm from the cutting edge of the knife of the distal end and ending in 50 mm. In a preferred form of mode, a numerical scale can be recorded next to the holes (26), in the form of laser markings or any other known in the art.

Distal end (front) (knife portion) This limb consists of a head portion consisting of: 1) A trapezoidal razor, attached to the opposite end of the head portion, with the sharpened distal cutting edge preferably concave or "V" shaped (fish mouth), with the following recommended dimensions: • Maximum length: 14 mm • Length in the concavity (backmost point): 10 mm • Height: 4 mm • Width: 1 mm It is recommended that the sharp distal cutting edge be moderately and not too sharp, in order to easily cut through the TCL (106), but with a certain degree of resistance, improving the surgeon's sense of touch of the cut that is leading to cape. 2) A solid, dull, finger-like plug attached to the top edge of the blade, in continuity with the shaft neck, with the following preferred dimensions: • Maximum length: 10 mm • Diameter: 1 mm The tip of this finger-like plug should preferably extend beyond the apex of the knife concavity by at least 4 mm. In this preferred form of embodiment, a metal sphere (32) with approximately 2 mm in diameter is attached to its tip, preferably positioned eccentrically outwards, in order not to decrease the width of the knife portion. 3) A solid, dull, finger-like plug attached to the lower edge of the blade, in continuity with the shaft neck, with the following preferred dimensions: • Maximum length: 13 mm • Diameter: 1 mm This pin should extend preferably beyond the apex of the concavity of the knife of approximately 6 mm, projecting therefore, in front of its similar. 4) A cannulated finger-like plug, attached to said solid, dull, finger-like lower plug, or alternatively, replacing it completely, attached directly to the underside of the knife, with the same dimensions and position characteristics as the finger. solid cylinder in continuity with the neck of the shaft, and, in a preferred form of embodiment, also with a beveled distal end, with the bevel oriented from top to bottom and front to back with the following preferred dimensions: • Maximum length: 13 mm • Outside diameter: 2 mm • Inner diameter: 1 mm • Bevelled distal end preferably Three other key features of the fasciotome head portion (25) are the following: 1) the width between the bottom surface on the two solid finger-like pegs (22; 24), attached to each side of the razor (21). ), is in the order of approximately 4 mm because we have found that the thickness of the transverse carpal ligament can exceed 3 mm in adults. The 4 mm spacing, therefore, prevents the incidence of such pins in the ligament which could prevent the normal progress of the knife through the ligament during the cutting process. Another, 2), is that the length of the solid top peg similar to a finger (23) does not need to extend approximately more than 4 mm relative to the most distal edge of the razor (21) because, especially if a sphere metal (32) is coupled to the tip of the plug, as recommended in the preferred form of mode, which is sufficient to prevent any poor guidance of the device. 3) Similarly, the length of the lower cannula similar to a finger (20; 24) does not need to extend approximately more than 6 mm in relation to the most distal edge of said razor (21) because, during the cutting process of the transverse carpal ligament (TCL) (106), the instrument is oriented along the entire length of cut by the flexible metal guide wire (33) inserted in said cannulated pin similar to a finger and not by the same pin. The reduced length that comes out of the pins helps prevent any possible interference from the head portion of the instrument against the tissues.

Cutting or fasciotome knife with a curved 90 ° angle shaft (41) (Figure 16) This cutting knife or fasciotome (41) can be manufactured, by one of several means known in the art, with biocompatible material, in two different forms: "disposable" and "non-disposable" or "permanent". 1) The "disposable" fasciotome consists of: 1) a front or distal knife portion made of surgical stainless steel or any other biocompatible, high strength alloy, such as those described for the cannulated guide bar (28) manufactured by one of several means known in the art, without this meaning that we are facing a new instrument, together with 2) a disposable back handle and / or rear axle, manufactured by one of several means known in the art, with a biocompatible material resistant to high temperatures, eg, high density polyethylene or another of the plastics family. The posterior bank can have any size or shape that adjusts to the economic characteristics of the surgeon and / or the convenience of industrial manufacturing, without this signifying that we are dealing with a new instrument. 2) The permanent or "non-disposable" fasciotome can be manufactured, by one of several means known in the art, 1) as a completely metallic piece, made of surgical stainless steel or any other high-strength metal alloy, such as those described for the cannulated guide bar (28) or 2) to have the same characteristics as those described for the disposable fasciotome, with the difference that the plastic or other non-metal, biocompatible material must have the ability to withstand high temperatures repeatedly, as It happens during the repeated sterilization processes.

Structural parts and preferential dimensions The remaining structural parts of the cutting knife / fasciotome (41) and their preferred dimensions, which can be altered for reasons of industrial manufacturing convenience or to suit the economic characteristics of the surgeon, without this meaning that we are facing a new instrument, continue: Shaft or stem Proximally with a 90 ° angle bend, it can be attached to any kind of appropriate handle, as described earlier in this document, with the following preferred dimensions and morphological characteristics: Up to the angle of curvature: of parallelepiped shape and quadrangular section and the following preferred dimensions: • Length: 30 to 60 mm • Height and width: 5 mm After the angle of curvature: pyramidal and proximal quadrangular section, in continuity with the preceding portion of the bar, gradually increasing towards its distal end, assuming a pyramid shape, flattened on the transverse axis, with greater height than width, with The following preferred dimensions: • Total length: 30 to 50 mm • Height: in the angle of curvature: 3 to 5 mm; at the distal end: 2 to 3 mm • Width: in the angle of curvature: 3 to 5 mm; at the level of the distal end: 1 to 2 mm Distal end (head; front) / (razor portion; This tip consists of: 1) A knife holder with two solid finger-like pegs (22; 23) at the tip, extending forward above and below the knife, symmetrically, by a distance, in a preferred form of mode, approximately 6 mm in relation to the most distal edge of the knife. Alternatively, the lower end of the knife may be flat or rounded at the end, extending below the knife by the same distance. 2) A trapezoidal knife (Figure 12), attached to the opposite end of the head portion, contained between the two pins mentioned above, with the sharply distal cutting edge preferably concave or "V" shaped (fish mouth) , with the following recommended dimensions: • Maximum length: 14 mm • Length in the concavity (backmost point): 10 mm • Height: 2 to 3 mm • Width: 1 to 2.5 mm It is recommended that the edge of the sharp distal cut is moderately and not too sharp, in order to easily cut through the antebrachial fascia (405A), but with a certain degree of resistance, helping the surgeon to have the sensation of cutting is taking place. 3) At the tip of each finger-like plug is attached, in a preferred form of embodiment, a metal sphere (42), with the preferred size of approximately 2 mm, preferably placed eccentrically outwards, for the purpose not to decrease the width of the knife portion. Alternatively, they can be centrally joined at the tip of the pin, provided that the spacing between them is at least 2 mm. This width is not as critical as in the case of the transverse carpal fasciotome of the right axis (25) because the purpose of this knife is to cut blindly through the distal antebrachial fascia, which is no thicker than 1 mm in adults. Therefore, a knife width of 2 to 3 mm is appropriate for this instrument.

The purpose of such spheres is to increase the bluntness of the tip of the pins that surround the blade, making it virtually impossible for the instrument to cut through the fascia in any direction other than the planned one (vertically upwards, parallel to the longitudinal axis). of the forearm).

Guide cannula (40) (Figure 17) A guide cannula (40) with a closed but fenestrated distal end and an open proximal end, the cannula provided with a longitudinal slot (39) extending from a point adjacent the distal cannulated end to a point adjacent the open proximal end. The cannula may have a C-shaped or D-shaped inner cross section with the flat part of the C or D shape positioned along the edge of the longitudinal groove.

This grooved, fenestrated end tip cannula is a modification of a common grooved pin cannula, as described below: a) Includes a fenestration - circular hole (33A) at the front end of the cannula, in the preferred form of mode, with approximately 1.5-2 mm in diameter, to allow the passage of the flexible metal guide wire (33) and mentioned in this document. b) In a preferred embodiment, there is also an arc of restraining metal or arc brake (37) extending approximately 2 mm above the level of the inner edge of the cannula, with a diameter of approximately and attached approximately 3 mm proximal with the inner edge of the distal end of said cannula. This arch brake helps to move aside the soft tissues below the transverse carpal ligament (106) during the insertion of said cannula (40) and improves the surgeon's manual sensitivity of the lower surface of said ligament (106). It also helps to restrict the final progress of the knife (21) of said fasciotome (25), being another element that prevents the knife from unwanted deviations towards the palm. c) At the open distal end of said cannula (40), a pair of handles with two end sides (38), each with the general shape of a semicircle fold in half at an angle of 90 °, are attached, forming two L-shaped sheets, of which the horizontal is attached to said axis of said cannula, with the preferred dimensions of approximately 25 mm high by 25 mm wide and, in a preferred form of mode, recorded with multiple holes round, like a network. The L-shaped configuration allows a comfortable and secure grip of the instrument with any of the operator's hands. The morogy of "red" significantly decreases the weight of the piece; the multiple fenestrations make the instrument lighter.

Operating procedure An explanation of the operative technique, including the inventive aspects of the method and devices disclosed in this document is achieved by describing the steps of the method with reference to the drawings and instruments.

After a patient has been anesthetized and the limb has been prepared properly covered, first, several marks are identified and marked as shown in Figure 1, that is: 1) the pisiform bone (105) (where the proximal ulnar junction of the transverse carpal ligament (TCL)); 2) the distal tendon of the long palmar muscle (104) at the level of the distal palmar crease of the wrist; 3) the Kaplan cardinal line (207) and; 4) two lines (202; 203) as a continuation of, respectively, the radial and ulnar edges of the ring finger. The cardinal line of Kaplan is drawn, as it is classically described, from the apex of the interdigital space between the thumb and the index finger, towards the ulnar side of the hand, parallel to the proximal palmar crease. The intersection of this line (207) with the continuation line of the ulnar border of the ring finger (203) corresponds to the hook of the hamate bone (that is, the distal ulnar junction of the TCL). The area between the two continuation lines (202) and (203) of the ring finger is considered a "safe zone" where the transverse carpal ligament (TCL) can be divided with minimal risk to the underlying structures.

A transverse incision (305) is made, usually one centimeter, through the distal palmar crease of the wrist, beginning one or two radial millimeters to the middle edge of the long palmar tendon (104), whenever present, extending towards the cubital. Only the skin is cut markedly. This prevents any iatrogenic damage to the underlying structures, that is, the superficial palmar branch of the median nerve radially and medially medially medially. The skin is retracted with skin hooks as shown in Figure 2 (401; 401A) and frankly dissected further with fine dissection scissors (not shown). Some subcutaneous fat and superficial fibers of the antebrachial fascia are usually present. These are separated and retracted (not shown). Any deeper fat protruding from the operative field is cut and removed to the extent necessary to clarify the visualization of the deep antebrachial fascia of the palmar carpal ligament (not shown). Otherwise, the fat simply retracts proximally and distally into the palm.

With the wrist slightly extended, the area corresponding to the junction of the distal edge of the palmar carpal ligament (405A) and the proximal edge of the transverse carpal ligament (405) is lifted with a pair of fine forceps (406) and cross-sectioned and, optionally, also vertically, creating a defect in the shape of a diamond, with an extension similar to that made on the skin.

A blunt curved dissector, e.g., McDonald (not shown), is first passed proximally under the antebrachial fascia (405A) to separate any fascial aggression, i.e., from the median nerve to said fascia, followed by a dull bar of 4. mm in diameter, cannula inserter or round obturator (not shown) to further verify which cleared passage has been established. Once it is found that the aforementioned instruments can freely pass into the proximal forearm, the fasciotome of the 90 ° angle axis (41) is brought to the operative field and its cutting edge is positioned in such a way that it extends the ligament Distal palmar carpal. The ligament is cut blindly an extension of approximately two centimeters by pushing the knife proximally, parallel to the main axis of the forearm, as shown in Figure 3. There is no need for visual control of the cut since the two spheres (32) in the The tip of the finger-like pegs (best seen in Figure 16) prevent the knife from coming out of the ligament. Afterwards, the same maneuver is repeated distally. The blunt curved dissector and blunt bar (601) are passed under the TCL past the distal edge of the ligament, as shown in Figures 4A and 4B, as can be verified by the surgeon's manual sensitivity of the position of the tip of the instrument under the ligament plus the protrusion of the same blunt tip in the area of the palm distal to the marked cardinal line of Kaplan (207). This sensitivity can be reinforced by means of digital pressure by the contralateral finger against the palm on the area of the output instrument (not shown).

Once the surgeon made sure that the passage below the TCL (106) is free of adhesions, the cannulated curved tip guide bar (27) is based on the same shape under the deep surface of said ligament in the "safe area". "between said two lines extending proximally from the edges of the ring finger, up to a point, more or less, 5 mm past the distal edge of the ligament, as shown in Figures 4A and 4C. This is to compensate for the distance between the tips of the fasciotome pegs of the transverse carpal ligament of the right axis (25) and its cutting edge.

The depth of penetration of the guide bar (27) can be objectively calculated using the laser markings on the concave surface of the bar (607) (best seen in Figure 4C). The surgeon should verify that the laser mark is closest to the distal edge of the surgical incision (305). These marks are also useful to indicate, at all times, in which direction the tip of the bar points.

Again, manual digital sensitivity should be used. A dull spatula (706) is placed on the skin of the palm pressing down distal to the tip that is felt on the cannulated guide bar with curved tip (27) and, with the help of an assistant, a flexible metal guide wire (33) (CONMED / Linvatec: Double Armed Suture Needle, REF 8535), is passed along the lumen of the bar until its sharp tip is made to come out through the skin of the palm as shown in the Figures 5A and 5B. The surgeon should note that the tip of the needle is, in fact, positioned in the "safe zone", in line with the ring finger and less than 10 m away! to the marked cardinal line of Kaplan. If not, the surgeon must remove the needle, reposition the cannulated guide bar with curved tip and try again.

Once the surgeon is satisfied with the position of the needle, said guide bar (27) is removed and the straight fasciotome of the transverse carpal ligament (25) comes into play as shown in Figure 6. The surgeon can start by placing the flat fasciotome in the upper part of the palm of the hand, in such a way that the cutting edge of the knife (21) is in proximity of said with the flexible metal guide wire (between three) in the exact place where this it comes out through the skin (not shown). Fenestration in the axis of the fasciotome closest to the distal edge of the surgical incision (305) will also provide the surgeon with an estimate of the length of the fasciotome that must be introduced through the TCL (106) to achieve a complete cut. ? Through this fenestration, the surgeon can introduce a metal device, such as a piece of wire (810) or simply a thin hypodermic needle, eg, 23G, slightly bent around the fasciotome axis, as shown in the Figures 6 and 7. This will serve as a guide so that the surgeon does not insert the fasciotome in the palm of the hand beyond the marked point, as shown in Figures 8A, 8B and 8C, therefore, preventing iatrogenic injuries to any structure of the hand distal to the distal edge of the TCL (106), that is to say the superficial palmar arterial arch (not shown). The next step is to feed the flexible metal guide wire through the lumen of the cannulated finger-like plug (20), as shown in Figure 6. Afterwards, the pins are oriented in such a way that the edge of the knife The fasciotome extends the proximal edge of the ligament as shown in Figure 7. The upper pin with its pointed ball (32) can be positioned accurately, under direct vision, on the upper part of the proximal edge of the ligament; The lower part of the razor end must also be placed with precision, under direct vision, below the lower surface of the ligament. This is a critical step in the operative technique.

Once the surgeon is absolutely sure of the position of the fasciotome knife relative to the edge of the TCL, the flexible metal guide pin (33) must be placed under tension, with the help of an assistant who pulls it in opposite directions with, for example, heavy needle supports (not shown). At this point, it is also useful if you slightly lift the needle in order to push it against the lower surface of the ligament. With this maneuver, the hand is brought to a natural or slightly extended position. The fasciotome (25), under the guidance of said needle (33) is pushed all the way distally through the ligament, cutting it, until its distal tip rests against the deep surface of the palmar skin as shown in Figures 8A , 8B and 8C. Also, at the end of this maneuver, the wire marker should be at the level of the proximal edge of the TCL, as shown in Figure 8A.

Optionally, before the introduction of the knife (25), the cannulated, cannulated tip cannulated guide (40) can be advanced first along the flexible metal guide wire (33) into the palm of the hand, until its end rests against the lower surface of the skin, at the point where the needle crosses the skin of the palm, from deep to the surface, as shown in Figures 9A and 9B. The rational for this alternative is to further increase safety, the cannula protects the tissues below the TCL (106). After the slotted cannula (40) is in place, the fasciotome (25), under the guidance of the flexible metal guide needle (33) is to feed through its cannulated lower finger-like pin (20), As previously described, it slides over the longitudinal slot of the cannula, as shown in Figure 9C, all the way through the TCL as shown in Figure 9D.

After the TCL (106) is cut, we remove the instruments and routinely verify in order to check and document that the ligament was completely divided. For this purpose, we lift the palmar skin and its underlying fat layer with an elevator (not shown) and insert into the wound a 0 ° angle scopium (not shown). If there is doubt about some of the remaining fibers in the distal part of the ligament then we insert (not shown), under the direct vision of the scopio, a Stephenson type knife and cut through those more distal fibers. Otherwise, only one image is taken for documentation purposes. The palmar skin is closed with two or three absorbable stitches (not shown) and The hand is properly bandaged.

Claims

NOVELTY OF THE INVENTION Having described the present invention as above, it is considered as a novelty and, therefore, the content of the following is claimed as property: CLAIMS

1. A set of surgical instruments for precision cutting, characterized in that it comprises at least one cutting knife or fasciotome (25) comprising an elongated shaft with a distal-forward end - with at least one cannulated peg similar to a finger (20). , 40) at the distal lower end of the device, a razor portion with the knife (21) shielded at its ends by a dull upper pin or a dull upper and lower pin (22, 23) similar to a projecting finger on the opposite side of the knife, and in such a way that a flexible guide wire needle (33) is suitable for guiding the knife portion of said knife or fasciotome (25) during the cutting process.

2. The set of surgical instruments according to claim 1, further comprises a cannulated guide bar (27) having means (28, 29, 30, 31) to allow the passage and guidance of the flexible guide wire needle (33) that it is suitable for guiding the knife portion of said knife or fasciotome (25) during the cutting process.

3. The set of surgical instruments according to claim 1 or 2, characterized in that the surgical knife or fasciotome comprises: an elongated shaft with a distal (leading) end with at least one cannulated peg similar to a finger (20); a razor portion with the knife (21) armored at its ends by a dull top pin or a dull top and bottom pin (22, 23) similar to a finger, projecting to the opposite side of the knife and said dull plug a finger-like upper portion (23) projects distally less than its counterpart (22), and at least one metal sphere (32) is connected to the tip of the finger-like superior blunt plug (23).

4. The set of surgical instruments according to any of claims 1-3, characterized in that the cannulated finger-like peg (20, 24) of the surgical knife or fasciotome (25) is connected to either the center, right or left side of the lower distal end of the device.

5. The set of surgical instruments according to any of claims 1-4, characterized in that the surgical knife or fasciotome (25) has two cannulated pegs similar to a finger (20; 24) parallel and a central peg similar to a finger, solid , dull (22).

6. The set of surgical instruments according to any of claims 1-4, characterized in that the surgical knife or fasciotome (25) comprises guide holes (26) in the distal shaft (25), in at least two of its edges or faces, located at an equal distance between them, and in known distance from the front end of the instrument.

7. The set of surgical instruments according to any of claims 1-6, characterized in that the surgical knife or fasciotome (25) comprises a proximal-posterior handle (34) with a longitudinal axis and a concavity towards the opposite side of the shaft, attached thereto in a shape that does not exit below the lower surface of said shaft, allowing convenient support of the thumb.

8. The set of surgical instruments according to any of claims 1-7, characterized in that the surgical knife or fasciotome (25) comprises, at the distal end with a knife portion (21), spheres (32) connected on an orthogonal axis in the main shank of the knife or fasciotome (25).

9. The set of surgical instruments according to any of claims 1 - 8, further comprises a second knife or fasciotome (41) with the main shaft bent at a 90 ° angle, of the knife, coupled to a handle, with pins dull upper and lower finger-like (42), in their preferred form of embodiment, with a metal sphere attached to the tip, preferably at least 2 mm in diameter, preferably in an eccentric shape.

10. The set of surgical instruments according to any of claims 1-9, further comprises a guide cannula (40) having means (37, 39) to allow the passage and guidance of a flexible guide wire needle (33) suitable for guide the knife portion of said knife or fasciotome (25) during the cutting process.

11. The set of surgical instruments according to the preceding claim, characterized in that the guide cannula (40) is a straight, elongated cannula having a closed distal end and an open proximal end, and a longitudinal slot (39) capable of accommodating a needle flexible metal guide (33) and guide the knife or fasciotome (25), wherein said open, proximal end of said cannula has at least two end-side handles (38), and said closed distal end of said cannula is fenestrated ,. by means of a hole (33A) that allows the passage of the flexible metal guide needle (33).

12. The set of surgical instruments according to claims 10 or 11, characterized in that the guide cannula (40) has, on its upper edge, a restraining metal arc or semicircular arc brake (37), suitable for helping to restrict the final progression of said knife (21) of said fasciotome (25), preventing the knife from being deviated towards the palm, and also suitable for moving aside the soft tissues below the transverse carpal ligament (106) during the insertion of said knife. cannula (40).

13. The set of surgical instruments according to any of claims 10-12, characterized in that the guide cannula (40) has a longitudinal groove (39) for accommodating the flexible metal guide needle (33) and has ears or handles of sides of end (38) 'to manipulate the device.

14. The set of surgical instruments according to any of claims 2 - 13, characterized in that the cannulated guide bar (27), comprises a cannulated cylindrical bar (28) with two open ends, of which the distal is curved (29).

15. The set of surgical instruments according to any of claims 2 - 14, characterized in that the cannulated guide bar (27) comprises, at the most distal edge, a curved tip with a projection, such as a tooth or nail (30; 31) and on the axis, on the side of the concavity of the curve, a recorded metric scale (28). SUMMARY OF THE INVENTION A method and a set of instruments are disclosed particularly for carpal tunnel surgeries allowing a precision cut in the transverse carpal ligament (TCL) without direct vision or exposure of the ligament, except for its most proximal edge, but with guidance and safety of the cutting knife, eliminating or, at least, greatly diminishing, the probability of cutting lines in the wrong direction and inadvertent (iatrogenic) injuries to the surrounding structures, comprising, in a preferred embodiment: a cannulated guide bar with unique shape , through which passes a flexible metal guide wire (33) which serves as a guide line for a single-shaped cutting knife or fasciotome (25) having a cannulated peg similar to a finger at the lower edge of the knife portion of the knife plus, in a second embodiment of the invention, a sphere (32) coupled to the tip of the superior blunt plug similar to a finger present at the upper edge of said knife portion of said knife; a uniquely shaped or fasciotome cutting knife with a 90 ° curved shaft with, in a second embodiment of the invention, a pair of spheres coupled to the tip of two blunt finger-like pins and a slotted guide cannula (40) with optional single form with a fenestration at its end tip allowing the passage of the flexible metal guide wire (33) and, in a second embodiment of the invention, also a metal arc of restraint or arch brake (37) by of its distal extremity and in its two posterior ears / handles for its proper handling.